1. Field of the Invention
The invention relates to storage of information, and more specifically to a system and method of linking observation data, categories of care data, and action data.
2. Description of the Related Technology
In most service industry occupations, there is a need for record keeping in order to track the progress of the object of care. For example, doctors keep records concerning each of their patients, mechanics keep records of each serviced vehicle, a school administration office may keep discipline records for each student, and a technical support department may keep records of each of their callers. These records are generally taken in an attempt to allow future readers to quickly ascertain the past history of the specific object of care (object of care and object, as used herein, refer generically to the person or item receiving the service, such as a patient, client, customer, automobile, student, etc.). In addition, many records attempt to show a connection between observations made regarding the object, a diagnosis of each condition, and a history of actions taken in an attempt to remedy each condition.
Record keeping has been accomplished in the past using a variety of different methods. For example, a doctor may use a blank piece of paper to write down his patient observations, diagnosis, and treatments given. This record may then be filed in a patient file until the next patient visit. When the patient next visits the doctor, there is no orderly method of locating observations, diagnosis, and actions taken by the doctor on prior visits. The doctor typically must skim the prior record to find the needed information. In addition, it may be difficult, if not impossible, to determine which observations led to each diagnosis, and what actions were taken for each diagnosis. Furthermore, if the doctor wants to add additional observations that relate to a diagnosis given on a prior visit, there is no physical space on the paper and no method of easily indicating that the new observations are directly related to the prior diagnosis. This problem becomes more apparent when a patient has multiple diagnoses. Similarly, if the doctor wishes to record additional treatments given for a prior diagnosis, they are likely listed on the next available blank line on the paper, which may not be adjacent to the prior diagnosis for which the treatments are prescribed. This may make it difficult to quickly determine what observations and diagnosis led to the newly listed treatments. In other words, the reader must decipher which findings led the writer to believe specific problems existed and for which specific problems which actions were taken. Thus, a record from which a reader may easily ascertain 1) why the doctor thought specific problems existed and 2) what the doctor prescribed for each problem, is desirable. It may be very time consuming to determine the answers to these questions with current medical records
In another existing method, the doctor may divide findings, or observations, regarding the patient into Subjective (reported by the patient) and Objective (observed by the doctor on exam) observations. The doctor may then record in a different section an assessment of why particular findings caused the doctor to think that there is a particular problem, what the probability of that problem is and the diagnosis. From there, the doctor may record plans, or actions, to hopefully remedy patients problems. This method of recording data is commonly known as the S O A P method. The SOAP model was first introduced in the article titled, “Medical records that Guide and Teach” by Lawrence L. Weed, M.D. (N Engl. J. Med 1968; 278: 593-600) and relates generally to the problem oriented medical record. More specifically, SOAP refers to the process of recording subjective and objective observations, diagnosed problems or situations, and scheduled actions or treatments. Using the SOAP model, the doctor is ideally supposed to write a SOAP note for each perceived problem in the patient. In many cases, some findings are used in the SOAP note for more than one problem and even more frequently plans may be performed for more than one problem. Thus, the SOAP model inherently involves repeated double entry of observations, diagnoses, and actions. A system that prevents double entry of information is desirable.
Previous methods may use paper medical record forms that have boxes for entry of various types of data. Unfortunately, it is difficult for a service provider to determine how much of a particular type of data will need to be recorded, and, thus, the box may constrain the space leading to either incomplete data collection or notes scribbled in margins nearby or elsewhere on the form in another box.
In one prior medical record embodiment, the medical records are source oriented with data stored according to its source. For example, lab results may be kept together, the doctors notes may be kept together and x-ray reports may be kept together. They may all be kept in one chart, but creating a mental model of the patient at any given point in time requires paging through the records from a specific point in time in each of the source groupings.